Method and Apparatus for Endoscopic Ligament Release

ABSTRACT

A method, apparatus, and system for cutting anatomic members, such as ligaments, in surgical procedures such as carpal tunnel release, plantar fasciotomy, gastroc release, cubital tunnel release, and tarsal tunnel release is disclosed. The apparatus includes a guide tool for guiding a knife and a scope during surgery which may be employed with a translating knife. Relevant features include a knife stop for preventing the knife from inadvertently raising out of the knife channel, indicia viewable to show the proper orientation for the guide tool, a self dilating tip and channel design on the guide tool, a cover piece and/or pivotable panel system for preventing ligaments and other anatomy from getting caught in the guide tool, a pivot pin and groove system for stabilizing the knife and also assuring that the knife blade is not inadvertently raised out of the channel, and a use indicator employable to prevent re-use of the device.

This application is a Continuation in Part Application to U.S. patentapplication Ser. No. 13/183,020 filed on Jul. 14, 2011, which claims thebenefit of U.S. Provisional Application No. 61/364,128 filed on Jul. 14,2010, both of which are fully incorporated herein by reference.

FIELD OF INVENTION

The invention pertains to methods, apparatus, and systems for performingendoscopic ligament release surgery, such as carpal tunnel release,plantar fasciotomy, gastroc release, cubital tunnel release, and tarsaltunnel release surgery, and similar surgical procedures on anatomicmembers.

BACKGROUND

Carpal tunnel syndrome occurs when the median nerve is squeezed where itpasses through the carpal tunnel, thereby causing insanguination of thenerve, which leads to numbness, a cold feeling, and/or pain in the handand fingers. The carpal tunnel is an anatomic passageway at the base ofthe wrist through which the median nerve and the flexor tendons for thefingers of the hand pass. It is defined by the carpal bones of the handand the transverse carpal ligament. Carpal tunnel syndrome is commonlycaused by highly repetitive hand motions over a number of years. Forinstance, carpal tunnel syndrome is common in certain professionals suchas secretaries and other professionals who type on a keyboard regularly,carpenters, dentists or anyone who performs the same hand motionsrepeatedly and regularly.

The current standard of care for alleviating carpal tunnel syndrome isto incise the transverse carpal ligament to open up the carpal tunneland release the pressure on the median nerve. With few exceptions, mostpeople can manage daily activities with a severed transverse carpalligament with almost no adverse effects.

The particular current procedure for carpal tunnel release is anendoscopic or arthroscopic procedure in which an incision is made in thewrist proximal of the carpal tunnel. An endoscope with a camera isinserted into the incision and through the carpal tunnel to allow thesurgeon to visualize the carpal tunnel, and, particularly, thetransverse carpal ligament, and then a knife is inserted alongside theendoscope to cut the transverse carpal ligament.

SUMMARY OF INVENTION

The invention pertains to a method, apparatus, and system for cuttinganatomic members, such as ligaments, in surgical procedures such ascarpal tunnel release, plantar fasciotomy, gastroc release, cubitaltunnel release, and tarsal tunnel release. The apparatus includes aretrograde knife and a guide tool for guiding the knife and a scopeduring surgery. Relevant features include a knife stop for preventingthe knife from inadvertently raising out of the knife channel,indicators showing the proper orientation for the guide tool, a selfdilating tip and channel design on the guide tool, a cover piece and/orpivotable panel system for preventing ligaments and other anatomy fromgetting caught in the guide tool, a pivot pin and groove system forstabilizing the knife and also assuring that the knife blade is notinadvertently raised out of the channel, and a use indicator forpreventing re-use of a single use device.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a diagram illustrating use of one particular endoscopic carpaltunnel release apparatus and method in accordance with the prior art.

FIG. 2 is a perspective view of a guide in accordance with oneparticular embodiment of the invention.

FIG. 3 is a close up view of the distal end of the guide of FIG. 2.

FIG. 4A is a perspective view of a guide in accordance with a secondembodiment of the invention viewed from a first perspective.

FIG. 4B is a perspective view the guide in accordance with the secondembodiment of the invention viewed from a second perspective.

FIG. 4C depicts a mode of the device in a view similar to that of 4Ashowing a shorter version without the extending handle portions at theproximal end.

FIG. 4D depicts a mode of the device in a view similar to that of 4Bshowing a shorter version without the extending handle portions at theproximal end.

FIG. 5 is a perspective view of the distal portion of a guide inaccordance with a third embodiment of the invention.

FIG. 6A is a perspective view of a guide in a first condition inaccordance with a fourth embodiment of the invention.

FIG. 6B is a perspective view of the guide of the fourth embodiment in asecond condition.

FIG. 7A is a cross sectional side view of the longitudinal member of aguide in a first condition in accordance with a fifth embodiment of theinvention.

FIG. 7B is a cross sectional side view of a distal longitudinal memberof a guide in a second condition in accordance with the fifth embodimentof the invention.

FIGS. 8A and 8B show a cover member and guide, respectively, inaccordance with a sixth embodiment of the invention.

FIG. 9A is a transverse cross-section of a guide in accordance with aseventh embodiment of the invention.

FIG. 9B is a side view of a knife in accordance with the seventhembodiment of the invention

FIG. 9C is a top view of the guide and knife of FIGS. 10A and 10Bassembled.

FIG. 10A is a perspective view of a knife prior to sterilization inaccordance with an eighth embodiment of the invention.

FIG. 10B is a close up perspective view of the proximal end of the knifein accordance with the eighth embodiment.

DETAILED DESCRIPTION OF THE EMBODIMENTS

Referring to FIG. 1, one system available on the market today is theSEG-Way system offered by Core Essence Orthopedics, Inc. of FortWashington, Pa., USA. The SEG-Way system comprises, among other things,a guide 10 and a retrograde knife 12. As seen in FIG. 1, the guide 10compromises a longitudinal member 14, containing a channel 16. Thechannel 16 is for receiving the endoscope 20 and the knife 12side-by-side. A key feature of the SEG-Way system is that the endoscopeand knife are entirely independently manipulable. The guide furthercomprises a transverse member 19 at its proximal end comprising twowings 21 and 22 extending in opposition transverse directions from theproximal end 23 of the longitudinal member 14. The wings 21, 22 providea place for the surgeon to hold the guide as well as some stabilityagainst rotation about the longitudinal axis 24 of the longitudinalmember because the wings essentially rest upon the forearm 26 of theperson after the guide has been inserted through the incision 25.

In use, the incision 25 is made in the wrist proximal to the carpaltunnel 27 and the longitudinal member 14 of the guide 10 is advanceddistally into and through the carpal tunnel, thereby dilating the carpaltunnel. Once the guide 10 is fully inserted and through the carpaltunnel 27, the endoscope 20 is advanced through the first channel 16 toallow the surgeon to see the carpal tunnel, and particularly, thetransverse carpal ligament 30. Then, the knife 12 is advanced distallywithin the channel 16. As can be seen in FIG. 1, the knife comprises ahandle 34 and a distal segment 36 disposed at an angle 38 to each otherand has a hooked, retrograde blade 29 at the distal end of the distalsegment 36 that faces proximally and cuts when the knife is pulled backin the proximal direction. The angled junction 38 between the handle 34and the distal segment 36 of the knife 12 generally defines a pivotpoint about which the knife will be rotated after insertion and prior tocutting. More particularly, the knife 12 is inserted into the channel 16with the distal segment 36 lying flat in the channel 16 and flushagainst the bottom of the channel with the blade 29 concealed inside thechannel 16 until it is past the transverse carpal ligament so as not tocontact any anatomy. This inherently means that the handle segment 34will be angled upwardly. Then, the surgeon pushes down on the handle tocause the distal segment, and particularly, the retrograde blade to riseup out of the channel 16 so that it can engage the distal edge 30 a ofthe transverse carpal ligament 30 and cut it by drawing the knife 12back in the proximal direction.

FIG. 2 is a perspective view looking substantially from the proximal endof a guide member in accordance with a first embodiment of the presentinvention. FIG. 3 is a close up view of the distal end of the guidemember of FIG. 2. The guide 100 comprises a longitudinal member 101 anda transverse member 102. The transverse member comprising two wings 103and 105 extended laterally from the proximal end 104 of the longitudinalmember 101. The longitudinal member 101 defines two channels 107 and 109separated by a partition, such as a ridge 106 in a surface of thelongitudinal member for accepting a scope, such as an endoscope orarthroscope, and a knife, respectively.

One issue of which surgeons must be aware when using carpal tunnelrelease surgical systems of the type shown in FIGS. 1 and 2 is the factthat the cutting tip of the knife should remain concealed within theknife channel 109 so as not to accidentally engage anatomy when theknife is being inserted distally through the carpal tunnel. This, ofcourse, is achieved by holding the knife handle at an angle to thelongitudinal axis 108 so that the distal segment of the knife lays flaton the bottom surface 113 of the channel 109 as described above inconnection with FIG. 1. However, if the knife is advanced distally farenough into the channel to engage the endwall or distal wall 115 of thechannel 109, if that wall is at an obtuse angle to the longitudinal axis108 of the guide, the wall may divert some of the distally directedadvancing force on the knife upwardly, thereby deflecting the distal endof the knife, i.e., the blade to exit the safe area inside the channel109 and possibly cut anatomy inadvertently.

Thus, in accordance with this embodiment of the invention, the end wall115 of the channel 109 forms an angle 118 with the bottom 113 of thechannel 109 that is substantial enough that any distally-directedadvancing force on the knife is not easily redirected upwardly so as tocause the distal end of the knife to rise up out of the channel 109.This angle 118 may be a right angle (90°). However, it can be an acuteangle so that engagement of the end of the knife with the wall 115actually applies a downward force on the distal end of the knife.Generally, no downward motion of the distal end of the knife willactually occur because the distal segment of the knife already should beflush against the bottom 113 of the channel 109. However, if the surgeonis holding the knife at an incorrect angle so that the distal end of theknife is not flush against the bottom of the channel, the engagementwith the end wall 115 may actually help by pushing the distal end of theknife down into the channel until it is flush with the bottom surface113.

In other embodiments, the angle may even be slightly greater than 90°.Specifically, since there will be some friction between the knife andthe wall 115 such that contact between the end of the knife and the wallunder reasonably expected loads still would not result in the knifesliding upward along the end wall 115 and rising out of the channel.

Additionally, the ridge 106 between the endoscope channel 107 and theknife channel 109 helps prevent the endoscope and knife frominadvertently interfering with each other. Specifically, in priordevices having a single channel for containing both the endoscope andthe knife, the scope and knife would often cross over into each other'sspaces within the single channel, sometimes causing difficulty inindividually advancing, withdrawing, tilting, turning, or otherwisemoving the endoscope and/or knife. The present design with two channels107, 109 separated by a ridge 106 essentially keep each of the endoscopeand knife from crossing over into the channel of the other instrumentand interfering with it.

FIGS. 4A and 4B are right-side and left-side perspective views of asecond embodiment of the guide 200 illustrating another feature.Particularly, with respect to the human body, medical personnelgenerally adhere to certain semantic conventions for clarity. Forinstance, the term “medial” is generally used to describe a directiontowards the center of the body, and the term “lateral” is generally usedto describe a direction away from the center of the body. However, withrespect to the hands, this language is not sufficiently definite becausea person can hold one's hand in different orientations, e.g., with thepalm facing towards the sky or with the palm facing towards the ground.Accordingly, the terms medial and lateral are indefinite with respect tohands. Hence, with respect to the hand, the terms “ulnar” and “radial”often are used instead. Ulnar refers to the direction from the center ofthe hand towards the ulnar nerve. The ulnar nerve runs along the lengthof the hand on the pinky side of the hand. Accordingly, the ulnardirection is the direction transverse the length of the hand facing fromthe center of the hand towards the pinky as illustrated by arrow 13 inFIG. 1. Radial, of course, is the opposite direction, as illustrated byarrow 15 in FIG. 1.

FIGS. 4C and 4D are right-side and left-side perspective views of thedevice in similar configuration to that of FIGS. 4A and 4B but showing ashorter version without the two wing type projections at the proximalend in a mode which might be employed on other parts of the body such asthe feet.

When performing endoscopic carpal tunnel release surgery using a guidesuch as any of guides 10, 100, and 200, it is desirable to have thecamera on the radial side and the knife on the ulnar side because theguide is inserted to the ulnar side of the medial nerve. This places theendoscope against the medial nerve, which is preferred because itseparates the medial nerve from the knife for extra safety in avoidingaccidental nicking of the medial nerve with the knife. Accordingly, itis desirable to provide different guides for the right hand and the lefthand. Therefore, to help avoid confusion, the two guides should beclearly marked, such as with an L and an R for the left-hand andright-hand guides, respectively. FIGS. 4A and 4B, for instance,illustrate the left hand guide and, it can be seen that there is aprominent L printed on one of the transverse wings.

Nevertheless, there still tends to be confusion during surgery as to theproper choice and orientation of the guide. Accordingly, in addition toclearly marking the guide as left or right, each guide member is alsomarked to indicate which side of the guide 200 should be facing towardsthe radial direction and the ulnar direction. This may be accomplished,for instance, by printing the words “radial” 202 and/or “ulnar” 204 onthe sidewall of the channels as shown in FIGS. 4A and 4B.

FIG. 5 is a perspective view of the distal end of a guide 300 accordingto a third embodiment. Particularly, as previously described, the distaltip of the guide leads the guide into and through the carpal tunnel. Thecarpal tunnel is rather tightly packed with flexor tendons and themedian nerve. Accordingly, tip 301 is shaped to better assist indilating the carpal tunnel and spreading the various flexor tendons andradial nerve to create room for the guide to pass through the carpaltunnel.

More specifically, the distal tip 301 of the guide 300 is prow shaped inorder to ease the insertion of the distal tip of the guide into thecarpal tunnel and to assist in the dilation of the carpal tunnel and thespreading of the flexor tendons and the medial nerve to allow thelongitudinal member 302 of the guide to pass through the carpal tunnel.As can be seen, the distal tip is shaped like the prow of a boat.Particularly, it is pointy without being sharp and it is curved upwardslightly.

FIGS. 6A and 6B illustrate an alternative embodiment of the longitudinalportion 401 of a guide 400 designed to even further ease insertion ofthe longitudinal portion 401 of the guide into the carpal tunnel and tomore efficiently dilate the tunnel. In accordance with this embodiment,the longitudinal portion 401 of the guide 400 actually comprises twolongitudinal members 404, 406 that are collapsible and expandable in thetransverse dimension 402 relative to each other. In this manner, thelongitudinal portion 401 of the guide 400 can be initially inserted intoand through the carpal tunnel while in the collapsed condition shown inFIG. 6A in order to ease insertion by virtue of having a smaller profilein the transverse dimension (the ulnar/medial direction) and beexpandable to the expanded condition shown in FIG. 6B to further dilatethe carpal tunnel and provide the necessary room for the endoscope andknife within the longitudinal portion 401. In the exemplary embodimentillustrated in FIGS. 6A and 6B, the first longitudinal member 404defines the endoscope channel 408 and the second longitudinal member 406defines the knife channel 405. The second longitudinal member 406 is atransversely translatable L-shaped member. In the closed position, thebottom leg 407 of the L-shaped second longitudinal member 406 slidesinto a groove (not shown) under the endoscope channel 408 of the firstlongitudinal member 404 so that the vertical leg 409 of the L-shapedsecond longitudinal member 406 butts up against the ulnar-side wall 411of the endoscope channel 408. This essentially collapses the knifechannel 405 to nothing and reduces the cross-section of the guideportion 404. The longitudinal portion 404 of the guide 400 can beinitially inserted into and through the carpal tunnel in the collapsedcondition shown in FIG. 6A. Then, after initial insertion and, perhaps,after waiting a designated period of time to allow the carpal tunnel todilate and adjust to accommodate the collapsed longitudinal portion 401,the L-shaped second longitudinal member 406 can then be slidtransversely outwardly into the expanded condition illustrated in FIG.6B, with the bottom leg 407 of the L-shaped member 406 sliding out fromunder the first longitudinal member 404 to open the knife channel 405.

The mechanism for permitting the longitudinal member to be collapsibleand expandable may take many forms. One such mechanism comprisestransverse grooves in the bottom leg 407 of the L-shaped member 406 thatmate with pegs protruding from underneath the endoscope channel 408. Thetransverse grooves can slide laterally relative to the pegs. Thetransverse grooves may have detents at two positions to provide a higherresistance to transverse sliding when in the fully collapsed positionand the fully opened position. The movement between the collapsedposition and open position can be actuated by any number of mechanisms.For instance, a turnbuckle-type screw runs through a longitudinalchannel underneath the endoscope channel 408, the proximal half of thescrew being right-hand threaded and the distal half of the screw beingleft-hand threaded. Each half of the screw bears a matingly threadedwedge-shaped nut that sits within a mating cut out in the bottom leg 407of the L-shaped member 406. The proximal end of the screw protrudes fromthe proximal end of the longitudinal member and has a thumb wheel toallow the surgeon to turn it by hand. Instead of a thumb wheel, thescrew may have a contoured head that mates with an instrument, such as ascrewdriver, to turn the screw. When the screw is turned in onedirection, the mating threads in the wedges and on the screw cause thewedges 437, 438 to move toward each other; causing the edges of thewedges to travel along the adjacent edges of the cutouts, thus pushingthe L-shaped member 406 transversely outward.

This exposes (or creates) the knife channel 405, which is defined by theinner surface 409 a of upper leg 409 of the L-shaped second longitudinalmember 406, the upper surface 407 a of the bottom leg 407 of theL-shaped second longitudinal member 406, and the ulnar-side outersurface 411 a of the first longitudinal member 404. The endoscope andknife can then be advanced into their respective channels 408 and 405and the procedure performed. After the procedure is performed and theknife and endoscope are withdrawn from their channels, the screw may beturned in the opposition direction. The force of the wedge pushing theL-shaped second longitudinal member transversely outward is thusreleased and the surrounding forces of the flexor tendons, median nerve,and other anatomy in the carpal tunnel on the outer surface 409 b ofupper leg 405 of the L-shaped member 406 will push the L-shaped member406 back to the collapsed position shown in FIG. 6A. The guide 400 maythen be withdrawn while in this collapsed state. If desired, the edgesof the wedge nuts can be provided with pegs that fit within furthergrooves in the adjacent edges of the triangular cutouts so that the pegscannot escape from the grooves, but can only travel within the grooves.In this manner, turning the screw in the opposite direction willactually draw the L-shaped member back inwardly in and of itself withoutthe need to rely on any external forces from the tendons and/or medialnerve in the carpal tunnel.

FIGS. 7A and 7B illustrate a fifth embodiment of a guide 500.Particularly, FIGS. 7A and 7B are transverse cross-sectional slices ofthe longitudinal member 501 of the guide 500 in accordance with thisembodiment. FIG. 7A illustrates the closed position and FIG. 7Billustrates the open position. In this embodiment, the outer walls 545,547 of the endoscope and knife channels 507, 509 bear panels 551, 553that are rotatable on pins 555, 557 between a first position asillustrated in FIG. 7A and a second position as illustrated in FIG. 7B.

Initially and throughout most of the procedure, the panels remain in thefirst position and simply form part of the walls 545, 547 of the twochannels 507, 509. However, after the ligament has been cut and theguide 500 is to be withdrawn from the carpal tunnel, the panels 551, 553may be flipped into the closed position illustrated in FIG. 7B to helpprevent pieces of the cut ligament or other anatomy from falling intothe channels 507, 509.

Particularly, it is not uncommon for pieces of the cut ligament to hangdown into the channels of the longitudinal member 501 of the guide 500and potentially be pulled by the guide 500 as it is withdrawn, whichwould cause unnecessary pain and possible damage to the patient. Inaccordance with this embodiment, the panels 551, 553 can be rotated intothe second position shown in FIG. 7B. As can be seen in FIG. 7B, in thisposition, the panels 551, 553 block off a significant portion of thechannels 507, 509. As they are rotated up, the panels would tend to pushout any ligament that has fallen into the channel. Furthermore, as theguide 500 is withdrawn from the carpal tunnel, the panels willsubstantially prevent ligament strands and other anatomy from fallinginto the channel and potentially getting caught in the channels.

In the illustrated embodiment, the panels 551, 553 do not fully closeoff the channels 507, 509. This is acceptable because the ligaments tendto get caught on the edges of the channels rather than in the middles ofthe channels. However, if desired, the panels 551, 553 can be made wideenough to meet each other in the second position to completely close offall of the channels. Preferably, the panels 551, 553 run the entirelength of the channels, but shorter lengths that leave a small portionof the channels exposed at either the proximal or distal end of thechannels would be acceptable.

The mechanism for rotating the panels between the first and secondpositions can take many forms. In the illustrated embodiment, the panelsare fixedly mounted on longitudinal pins 555, 557 that run in holes 561,563 the full length of the channels 507, 509. The proximal ends of thosepins 555, 557 protrude from the proximal end of the longitudinal memberand bear thumb wheels for allowing the surgeon to rotate the pins 555,557. The panels 551, 553 can be fixable in any position, not just thefirst and second positions. For instance, at least the proximal ends ofthe pins can be threaded and nuts 565, 567 can be provided near theproximal end of each pin and so that the nuts can be rotated on the pinsas desired to abut the proximal end of the longitudinal member 501 andthereby lock the pins/panels in any desired orientation.

The panels 551, 553 also may be rotated and locked in the secondpositions to close off the channels during initial insertion of theguide 500 into and through the carpal tunnel. Particularly, althoughless common, it is possible for the transverse carpal ligament, flexortendons, medial nerve or other anatomy to get caught in one of thechannels 507, 509 during insertion too. Accordingly, it may be desirableto flip up the panels during both insertion and withdrawal of the guidefrom the carpal tunnel or other anatomical passageway.

FIGS. 8A and 8B illustrate aspects of a sixth embodiment of theinvention having some of the same advantages as the fifth embodimentdescribed above in connection with FIGS. 7A and 7B.

More particularly, in this embodiment, a cover piece 680 illustrated inFIG. 8A is provided to completely cover the channels 607, 609 in thelongitudinal member 601 of the guide 600 (illustrated in FIG. 8B) duringinsertion into and/or withdrawal. In this embodiment, the cover 607piece comprises two members 681, 683, one shaped to exactly fill theendoscope channel 607 and the other shaped to exactly fill the knifechannel 609. The two members 681, 683 are joined to each other through aproximal end piece 685. The cover piece is inserted simply by pushing itdistally into the longitudinal member from the proximal end openings 607a, 609 a of the channels 607, 609. The cover piece 680 fully fills bothchannels 607, 609.

In use, the cover piece 680 is inserted into the longitudinal member 601prior to insertion of the guide 600 into the carpal tunnel. The coverpiece 680 serves the purpose of closing off the channels, therebypreventing ligaments and other fibers from getting caught in thechannels as the guide is advanced into and through the carpal tunnel.Once the guide 600 is inserted, the cover member 680 can be withdrawnproximally to expose the channels 607, 609 so that the endoscope andknife can be inserted into their respective channels. If desired, afterthe procedure is performed, the cover member 680 may be reinserted intothe channels 607, 609 prior to withdrawing the guide 600 from the carpaltunnel in order to again close off the channels and prevent ligamentstrands and other fibers from getting caught in the channels as theguide is pulled out.

FIGS. 9A, 9B, and 9C illustrate a seventh embodiment of the invention.FIG. 9A is a transverse cross-section view through the guide of thisembodiment. FIG. 9B is a side view of the knife in accordance with theseventh embodiment. FIG. 9C is a top view of the knife in accordancewith the seventh embodiment. In this embodiment, two pin grooves 711,712 are provided in the knife channel 709 of the longitudinal member 701of the guide 700, the pin grooves 711, 712 are open to the proximal endof the guide. Mating pins 713, 714 for sliding in the grooves 711, 712are provided on the body of the retrograde knife 770. Hence, the heightof the pin grooves 711, 712 within the knife channel 709 and theposition of the pins 713, 714 on the knife 770 are selected so that,when the knife is inserted into the channel with the longitudinaldimension of the distal portion 771 of the knife 770 parallel to thechannel 709 and concealed within the channel 709, the pins 713, 714 meetthe grooves 711, 712 and can ride within the grooves in the longitudinaldirection, thereby allowing the knife 770 to slide freely in the knifechannel 709 in the longitudinal direction, but fixing the height of theknife in the channel at the location of the pins. The mating grooves711, 712 and pins 713, 714 provide a defined position about which theknife can be pivoted to raise the retrograde blade out of the channelfor cutting the ligament. More particularly, the height of the pivotpoint is fixed by the height of the grooves 711, 712. However, while thepivot pins 713, 714 define the precise axis about which the knife can bepivoted, the longitudinal position of those pins within the grooves isfreely and fully adjustable within the grooves.

The combination of the pivot pins 713, 714 and the pivot grooves 711,712 also provides increased stability to the knife 770 during distaladvancement of the knife into the channel 709 insofar as the height ofthe knife is vertically fixed in the channel at the point where thepivot pins are positioned on the knife. As long as the surgeon maintainsa neutral or upward force on the handle 772 of the knife, the distalsegment 771 of the knife will remain entirely in the knife channel 709.On the other hand, in the absence of the pivot pins and grooves, thesurgeon would need to be much more careful when inserting the knife toassure that the entire distal segment 771 of the knife 770 remained inthe channel 709. Even further, the pivot pins/grooves combination alsoprovides greater knife stability against roll (see arrow 747) about thelongitudinal axis 749 of the distal segment 771 of the knife 770.

The pivot pins 713, 714 should be positioned on the knife 770 at an axisaround which it is most desirable to pivot the knife. This will usuallybe at or very near the point 781 defining the base of the angle betweenthe handle portion 772 of the knife and the distal portion 771 of theknife. The diameter of the pivot pins 713, 714 should be very close tothe height, h, of the pivot pin grooves 711, 712 so that there is verylittle vertical play between the pivot pins and the pivot pin grooves,but should allow the pins to slide freely in the grooves. The groovesmay run the entire length of the knife channel so that the knife can beadvanced into the channel to any desired distance. However, inaccordance with another embodiment, the groove may have a definedlength, I, from the proximal end of the knife channel 709 so that theknife 770 cannot advance distally past the point where the pins 713, 714on the knife hit the ends of the grooves 711, 712. This length, forinstance, may be selected to prevent the distal end 773 of the knifefrom hitting the distal wall of the knife channel 709. This would beanother potential mechanism for preventing the end of the knife fromhitting the end wall of the channel and potentially being damaged and/oraccidentally riding up the end wall 710 and out of the channel 709inadvertently, as discussed above in connection with the embodiment ofFIGS. 2 and 3.

Although the various features disclosed herein have been described inconnection with different embodiments of a guide, it should beunderstood that any and all of the features of each embodiment may becombined in the same instrument in virtually any permutation.

In accordance with another aspect of the invention and with reference toFIGS. 10A and 10B, a portion 802 of the knife 800, preferably on thehandle 801 is composed of a material different than the rest of theknife, which material cannot survive an autoclaving process intact.FIGS. 10A and 10B show the knife prior to sterilization. This is adesirable feature because it will provide an easily identifiable visualcue that the knife has been autoclaved. More particularly, in accordancewith at least one embodiment, the entire system, including the guide,knife, and any other related instruments, such as a ligament rasp or aprobe, are single-use surgical instruments, i.e., they can only be usedonce and then should be discarded. However, it is not uncommon foreither medical staff or medical equipment resellers to inadvertently oreven intentionally attempt to re-use or re-sell medical equipment thatis intended only for a single use. In order to reuse any surgicalinstrument, it must be sterilized after the first use, which usuallyinvolves an autoclaving process. Accordingly, providing a portion 802 ofthe knife that is made of a material that cannot survive autoclaving,can provide a easy visual reference that the device has been previouslyused, and therefore should not be used again. In the embodimentillustrated in FIGS. 10A and 10B, the portion is a circular medallion802 near the proximal end of the handle 801. The knife 800 generallywill be made of a biocompatible metal, such as titanium or nitinol. Themedallion, however, may be made of a polymer that will melt or otherwisedegrade when subjected to a conventional autoclaving process (or anyother process that might be used to re-sterilize a medical instrument).

In one embodiment, the medallion may run through the entire width, w, ofthe handle so that, after autoclaving, a hole will be left in thehandle. However, in another embodiment, the button may only comprise asurface layer of material which, when destroyed reveals an underlyingnon-degradable material, such as the same material that the rest of theknife is made of, bearing a warning indicator indicating that the devicehas been used and should be not re-used, such as the words “Warning,this instrument has been used and should be discarded” or simply“Discard”.

Having thus described a few particular embodiments of the invention,various alterations, modifications, and improvements will readily occurto those skilled in the art. Such alterations, modifications, andimprovements as are made obvious by this disclosure are intended to bepart of this description though not expressly stated herein, and areintended to be within the spirit and scope of the invention.Accordingly, the foregoing description is by way of example only, andnot limiting. The invention is limited only as defined in the followingclaims and equivalents thereto.

What is claimed is:
 1. A guide tool for performing anatomical memberrelease surgery comprising: a longitudinal member having a proximal end,a distal end, a longitudinal axis, and a longitudinal surface extendingbetween the proximal end and the distal end; a first longitudinalchannel in the longitudinal surface of the longitudinal member forpositioning a knife therein, said longitudinal channel having a bottomsurface; said longitudinal channel being open to the proximal end ofsaid longitudinal member and extending toward said distal to an endwall; and a second longitudinal channel formed in said longitudinalsurface paralleling said first longitudinal channel and configured fortranslation of an endoscope therein.
 2. The guide tool of claim 1,additionally comprising: two wings extended laterally in opposingdirections from the proximal end of said longitudinal member; and saidwings providing a grip for a user of said tool for imparting force for asurgical insertion or rotation of said guide tool.
 3. The guide tool ofclaim 1 additionally including a partition extending between said firstlongitudinal channel and said second longitudinal channel.
 4. The guidetool of claim 2 additionally including a partition extending betweensaid first longitudinal channel and said second longitudinal channel. 5.The guide tool of claim 1 additionally comprising: at least onelongitudinal groove in said first longitudinal channel positioned apredetermined height above the bottom surface, the groove open to theproximal end of the longitudinal member; a knife said knife having; ahandle segment having a first longitudinal axis; a distal segmentextending from the handle segment and having a second longitudinal axisand a distal end, the longitudinal axes of the handle segment and thedistal segment being disposed at an angle to each other, and the knifeadapted to slide, with the distal segment first, into said firstlongitudinal channel in said guide tool at said proximal end of theguide tool; at least one pivot pin extending from the knife in adirection transverse to the longitudinal axes of the handle and distalsegment, said at least one pivot pin adapted to slide within the groovein said first longitudinal channel when the knife is inserted into saidfirst longitudinal channel; and whereby said at least one pivot pin inthe at least one groove define a pivot axis about which the knife can berotated when the knife is within said first longitudinal channel.
 6. Theguide tool of claim 2 additionally comprising: at least one longitudinalgroove in said first longitudinal channel positioned a predeterminedheight above the bottom surface, the groove open to the proximal end ofthe longitudinal member; a knife said knife having; a handle segmenthaving a first longitudinal axis; a distal segment extending from thehandle segment and having a second longitudinal axis and a distal end,the longitudinal axes of the handle segment and the distal segment beingdisposed at an angle to each other, and the knife adapted to slide, withthe distal segment first, into said first longitudinal channel in saidguide tool at said proximal end of the guide tool; at least one pivotpin extending from the knife in a direction transverse to thelongitudinal axes of the handle and distal segment, said at least onepivot pin adapted to slide within the groove in said first longitudinalchannel when the knife is inserted into said first longitudinal channel;and whereby said at least one pivot pin in the at least one groovedefine a pivot axis about which the knife can be rotated when the knifeis within said first longitudinal channel.
 7. The guide tool of claim 3additionally comprising: at least one longitudinal groove in said firstlongitudinal channel positioned a predetermined height above the bottomsurface, the groove open to the proximal end of the longitudinal member;a knife said knife having; a handle segment having a first longitudinalaxis; a distal segment extending from the handle segment and having asecond longitudinal axis and a distal end, the longitudinal axes of thehandle segment and the distal segment being disposed at an angle to eachother, and the knife adapted to slide, with the distal segment first,into said first longitudinal channel in said guide tool at said proximalend of the guide tool; at least one pivot pin extending from the knifein a direction transverse to the longitudinal axes of the handle anddistal segment, said at least one pivot pin adapted to slide within thegroove in said first longitudinal channel when the knife is insertedinto said first longitudinal channel; and whereby said at least onepivot pin in the at least one groove define a pivot axis about which theknife can be rotated when the knife is within said first longitudinalchannel.
 8. The guide tool of claim 4 additionally comprising: at leastone longitudinal groove in said first longitudinal channel positioned apredetermined height above the bottom surface, the groove open to theproximal end of the longitudinal member; a knife said knife having; ahandle segment having a first longitudinal axis; a distal segmentextending from the handle segment and having a second longitudinal axisand a distal end, the longitudinal axes of the handle segment and thedistal segment being disposed at an angle to each other, and the knifeadapted to slide, with the distal segment first, into said firstlongitudinal channel in said guide tool at said proximal end of theguide tool; at least one pivot pin extending from the knife in adirection transverse to the longitudinal axes of the handle and distalsegment, said at least one pivot pin adapted to slide within the groovein said first longitudinal channel when the knife is inserted into saidfirst longitudinal channel; and whereby said at least one pivot pin inthe at least one groove define a pivot axis about which the knife can berotated when the knife is within said first longitudinal channel.
 9. Theapparatus of claim 5 wherein the at least one longitudinal groovecomprises first and second opposing longitudinal grooves and the atleast one pivot pin comprises first and second opposing pivot pinsextending transversely from the knife.
 10. The apparatus of claim 6wherein the at least one longitudinal groove comprises first and secondopposing longitudinal grooves and the at least one pivot pin comprisesfirst and second opposing pivot pins extending transversely from theknife.
 11. The apparatus of claim 7 wherein the at least onelongitudinal groove comprises first and second opposing longitudinalgrooves and the at least one pivot pin comprises first and secondopposing pivot pins extending transversely from the knife.
 12. Theapparatus of claim 9 wherein the pivot pins are positioned adjacentwhere the distal segment of the knife meets the handle segment of theknife.
 13. The apparatus of claim 10 wherein the pivot pins arepositioned adjacent where the distal segment of the knife meets thehandle segment of the knife.
 14. The apparatus of claim 11 wherein thepivot pins are positioned adjacent where the distal segment of the knifemeets the handle segment of the knife.